A Guide to 6 Types of Tests

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

You just celebrated your 40th birthday and are wondering whether you should make a mammogram appointment – or wait 10 more years.

But wait, you recently read something about a new study saying mammograms aren’t necessary at all.

So what breast cancer screening should you have? And when?

There’s no quick and easy answer, because what’s best depends on your breasts, your age and your risk factors.

When it comes to breast cancer screening, no one-size-fits-all recommendation exists, and no diagnostic test is foolproof, says Travis Kidner, MD, a surgical oncologist at Rox Cancer Center in Beverly Hills, Calif.

“That’s why it’s important for women to know their family history and to discuss their personal risk of breast cancer,” he adds. “Then you and your doctor can develop a screening program that best fits your needs.”

We consulted with top breast cancer doctors to find out what you need to know about breast cancer screenings and diagnostics, which include more than mammograms.

Here’s a guide to 6 breast cancer detection methods:

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

1. MammogramsWhat is it? Mammograms –X-ray images of your breasts – are the most common, widely available and best-known breast cancer screening methods.

A mammogram allows doctors to see your breasts’ internal structure from top to bottom and side to side. Your breast will be compressed between two glass plates, so that the whole breast can be viewed.

But experts debate when to start having mammograms – and one large, widely disputed study says they may not make much of a difference anyway.

In its April 2015 breast cancer screening report, the US Preventive Services Task Force (USPST), a government panel of experts, reaffirmed its advice for women to start having mammograms at age 50 and every two years thereafter. The goal is to reduce overtreatment for slow-growing cancers that pose little threat and to reduce the number of false alarms on mammograms and unnecessary biopsies.
For women 40-49, the task force continues to recommend women consult with their doctor for an individualized decision to screen based on her family history and the benefits and harms of screening every two years.
The American College of Obstetricians and Gynecologists (ACOG) – a group of physicians that provides women’s health care - still recommends annual mammograms every 1-2 years for women in their 40s with an average risk for breast cancer. ACOG also recommends annual screening for women over 50.

Many doctors and major health organizations, including the American Cancer Society, American College of Radiology and the National Comprehensive Cancer Network, agree with ACOG’s recommendations for yearly mammograms starting at age 40.

One exception: Women with a close relative diagnosed with breast cancer before menopause should start mammograms 10 years earlier than the age at which the relative was diagnosed, ACOG says. So if your mom or sister got breast cancer at age 45, you would start having screenings at age 35.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

Further confusion came with the 2014 publication of a Canadian National Breast Screening Study (CNBSS) in the British Medical Journal. The study, conducted over a 25-year period, followed more than 90,000 women ages 40-59 – half of whom had annual mammograms and half of whom didn’t. The study concluded that annual mammography is no better at reducing mortality from breast cancer than that of physical examinations alone.

But many doctors refute the CNBSS findings, saying that the design of the study was flawed.

Women with palpable breast masses – that is, lumps that can be felt – were allowed in the CNBSS, even though they already had known symptoms, says Therese Bevers, MD, professor in the Department of Clinical Cancer Prevention at the University of Texas MD Anderson Cancer Center in Houston. If researchers knew this, they might have been tempted to send them for testing rather than assigning them to one of the groups at random, she argues.

Many other studies “report a significant reduction in breast cancer mortality for women in this age range [who have mammograms],” Dr. Bevers notes.

So what to do? Start yearly mammograms at age 40 or wait until you turn 50 and have them every two years?

Most doctors are sticking to ACOG’s guidelines to have mammograms sooner and more often.

“Every two years leaves too much room for women to fall through the cracks,” says Laura Kruper, MD, co-director of the Breast Cancer Program and director of the Cooper Finkel Women’s Health Center at City of Hope in Duarte, Calif. “I’m a firm believer in yearly tests. And I tell all my patients with normal risk to start mammograms at age 40.”

Pros: Mammograms are the gold standard of cancer screening. And new technologies are making them even more precise.

“Digital mammography has been a great advance in breast cancer screening,” Dr. Kidner says. “By being able to adjust the brightness, darkness or contrast of an image, it is easier to see subtle differences between tissues.”

Images can be stored and retrieved electronically, so doctors can easily share them and compare them with past mammograms. The radiologist can expand images, so digital mammograms have fewer false positives than old film mammograms.

And digital mammograms mean that women can get their results that day, rather than having to wait 48 hours.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

New 3-D digital mammograms – also called digital tomosynthesis – are offered at some centers. During this exam, a tube moves in an arc around the breast, taking as many as 16 images and transmitting them to a computer.

3-D mammograms take images in several different slices, which make catching abnormalities easier.

“A big study published in 2014 showed 3-D mammograms improve cancer detection by 29% and decrease false positive rates by 15%-20%,” says Beatriu Reig, MD, a radiologist and assistant professor in the Department of Radiology at Albert Einstein College of Medicine in New York.

On the horizon: Positron Emission Mammography (PEM) is a sophisticated, but still experimental, imaging technique. You get an injection of a small amount of radioactive material mixed with sugar, which cancer cells absorb faster than normal cells. You lie on a table that moves through a scanner and spits out computer images for a radiologist to interpret.

Like a PET scan for the breast, PEM creates computer images of chemical changes in tissue and shows promise in improving detection of early-stage breast cancer, even for women with dense breasts.

“But it isn’t ready for prime time yet,” Dr. Bevers says, noting that PEM isn’t being used at major clinics at this point.

Cons: Mammograms expose women to a low dose of radiation – “about the same level you’d get on a round-trip flight from Houston to Paris,” Dr. Bevers says.

A slightly higher dose of radiation is used for 3-D mammograms, but because the radiologist has more images to work with, the likelihood of a callback is reduced.

The PEM test exposes you to even more radiation than you get from a 2-D or 3-D mammogram.

“If we can get the radiation dose down, PEM may be a niche imaging tool for diagnosing high-risk patients,” says Mary Newell, MD, associate director of the Breast Cancer Center, Winship Cancer Institute, and associate professor of radiology at Emory University School of Medicine in Atlanta.

And let’s face it: Having your breasts squished is painful. However, compression is necessary to produce the clearest images. Some clinics now allow the patient to control the compression level with a button.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

Both false positives and false negatives are another problem with mammograms, often leading to unnecessary follow-up procedures and anxiety, as well as a false sense of security.

About half of US women screened annually for 10 years will be told they need further testing, and 7%-17% will have biopsies, according to the National Cancer Institute (NCI). Yet only 5 of the 100 recalled will have cancer.

Mammograms may miss cancers in women under age 30, those with dense breasts, and even some with rapidly growing cancers. As many as 6% of women with invasive cancer will have negative mammograms, according to the NCI.

That’s because cancer appears white on the screen – the same as dense breast tissue. Women with dense breasts should discuss additional testing methods with their doctors. (See www.AreYouDense.org for more information.)

Mammograms are more complicated for women who have implants. The technician has to position the breast and then carefully push the implant to the side, so that the breast tissue and muscle are compressed – not the implant.

“With the way implants are done now, you can still get the images,” Dr. Bevers says.

She dismisses the myth that mammograms can cause implants to rupture.

Cost: $120 and more. Insurance typically covers one mammogram annually (twice a year for women with breast cancer). Women on Medicare can get them free, and under the Affordable Care Act, mammograms are usually covered as a preventive test.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

2. UltrasoundWhat is it? If you have an abnormal mammogram, an ultrasound is usually the next step.

Ultrasounds send high-frequency sound waves through your body to create two-dimensional images of your breast, which are displayed on a screen. The clinician spreads a lubricating jelly over your breast and runs a hand-held transducer over the area.

An ultrasound can help your doctor determine whether a lump is a potentially malignant solid tumor or a benign cyst, which isn’t easy to determine on a mammogram.

Pros: Ultrasounds are good for women with dense breasts, which are harder to read on a mammogram. Two 2012 studies led by Jean Weigert, MD, a radiologist with Bradley Memorial Hospital and Health Center in New Britain, Conn., showed that ultrasound caught cancer in women with dense breasts, even after mammograms failed to reveal anything. Ultrasound also caught smaller, previously undetected cancers, the study found.

Another advantage: Radiation isn’t used in ultrasound.

Cons: Ultrasound doesn’t detect microcalcifications, small deposits of calcium that can indicate early-stage breast cancer, which generally shows up on a mammogram.

They take longer than mammograms to interpret, and the results depend on the technician’s skill, Dr. Newell says.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

3. MRI (Magnetic Resonance Imaging)What is it? MRIs use magnets and radio waves to produce multidimensional views of the breast on a TV screen.

MRIs are generally used only to screen women who have more than a 20% risk of breast cancer because of family history or gene abnormality, women under age 30 with a palpable mass, women who’ve had radiation cancer treatment, or as a follow-up to a suspicious finding on a mammogram.

During an MRI, you lie face down on a scanning table that moves through a tubelike machine. A dye may be injected into your breast to highlight tumors.

Cons: Despite their sensitivity, MRIs are so expensive that they’re not recommended as a screening tool.

MRIs also produce significantly more false positives than mammograms, according to the NCI.

Dr. Kruper compares them to a car alarm that’s triggered when a truck goes by.

“They pick up too many things in the breast and have doctors doing biopsies left and right,” she says.

Cost: $2,000 to $5,000 or more. Insurers will not pay for it as a routine screening tool.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

4. Molecular Breast Imaging (formerly called Thermogram)What is it? Molecular Breast Imaging (MBI) produces a 3-D image that shows the heat and blood-flow patterns on or near the breast’s surface. Unlike benign growths, cancerous tumors are extremely vascular, so a bright red pattern in the breast area might indicate malignancy.

However, MD Anderson is getting ready to launch a major study on what is now called MBI.

“Thermogram results with the old version were disappointing, but we haven’t given up on the technique,” Dr. Bevers notes.

Thermograms are approved by the Food and Drug Administration as an add-on screening tool for the mammogram.

Pros: No dyes, no compression and no radiation.

Cons: Previous studies have failed to show thermogram reliability for detecting breast cancer, despite calls by proponents that it should replace mammograms.

Most insurance companies don’t cover it.

False positives with thermograms, which require more tests, are a problem. Also, thermograms may miss slow-growing cancers. Studies on the more advanced MBI are just starting.

Cost: About $150 for a thermogram, but it’s rarely covered by insurance.

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

5. Clinical Breast ExamWhat is it? Your primary care doctor or OB/GYN performs a breast exam to check for palpable masses, unusual ridges or any other signs of breast cancer.

Pros: This simple, low-tech, hands-on exam can be a lifesaver.

“I cannot stress enough the importance of including an annual breast exam in conjunction with an annual mammogram,” Dr. Kidner says. “In many instances, my patients have had a normal mammogram, and yet during their clinical breast exam, I detected an abnormality that was found to be cancer.”

Cons: Even the most experienced doctor may miss small cancers, and by the time a lump is large enough to be felt, it may already be advanced.

Cost: Often covered by insurance as part of your routine annual checkup.

6. Breast Self-ExamWhat is it? Conventional wisdom tells us to do a monthly breast exam, with specific instructions on when and how to do it.

The new message is simpler: Get to know your breasts. A vast majority of palpable masses are found by women in the course of their daily activities, Dr. Bevers notes.

“We encourage women to pay attention to their breasts,” she says. “You know them better than anybody. If you feel something different – even if it’s only been a month since your last mammogram – call your doctor.”

Many women are confused about breast cancer screening. When should you start getting mammograms and how often? How effective are they at detecting cancer, and should you push for additional tests? Read on for the answers and more . . .

Pros: “Eight of 10 breast lumps are detected by women themselves, who bring them to the attention of their doctors,” Dr. Kruper says.

You can check yourself when you shower, dress or lie in bed.

Some women worry that they don’t know what to do. But a large Chinese study compared women who were taught to do breast exams every month with women who didn’t have any training. The results showed a negligible difference in cancers found.

Cons: Many small cancers aren’t detectable during a self-examination, so you shouldn’t rely on that alone.

What’s Your Breast Cancer Risk?
The biggest risk factor for developing breast cancer is simply being a woman, though a small percentage of men develop it, too. Fortunately, with better screening processes for early detection, breast cancer doesn't have to be fatal. Find out how at risk you are with this breast cancer quiz.

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